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Psychotropic Medication
Including Role of Gradual Dose
Reductions
What are they?
• The phrase “psychotropic drugs” is a technical
term for psychiatric medicines that alter
chemical levels in the brain which impact
mood and behavior.
Types of Psychotropic Medication
Antipsychotics
(used in the treatment of
schizophrenia and
mania)
Antianxiety Agents
Anti-depressants
Mood Stabilizers
(used in the treatment
of bipolar disorder)
Anti-obsessive Agents
Anti-Panic
Agents
Stimulants
(used in the
treatment of ADHD)
From NAMI website
From Choosing Wisely
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Lists
The Choosing Wisely lists were created by national medical specialty societies and represent
specific, evidence-based recommendations clinicians and patients should discuss. Each list provides
information on when tests and procedures may be appropriate, as well as the methodology used in
its creation.
In collaboration with the partner organizations, Consumer Reports has created resources for
consumers and providers to engage in these important conversations about the overuse of medical
tests and procedures that provide little benefit and in some cases harm.
Choosing Wisely recommendations should not be used to establish coverage decisions or
exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary
treatment. As each patient situation is unique, providers and patients should use the
recommendations as guidelines to determine an appropriate treatment plan together.
For Clinicians
Specialty society lists of things clinicians and patients should question
For Patients
Patient-friendly resources from specialty societies and Consumer Reports
Choosing Wisely – from ABIM
• American Geriatrics Society
• Released February 21, 2013; revised April 23, 2015
• Don’t use antipsychotics as the first choice to treat behavioral and
psychological symptoms of dementia.
• People with dementia often exhibit aggression, resistance to care
and other challenging or disruptive behaviors. In such instances,
antipsychotic medicines are often prescribed, but they provide
limited and inconsistent benefits, while posing risks, including over
sedation, cognitive worsening and increased likelihood of falls,
strokes and mortality. Use of these drugs in patients with dementia
should be limited to cases where non-pharmacologic measures
have failed and patients pose an imminent threat to themselves or
others. Identifying and addressing causes of behavior change can
make drug treatment unnecessary.
Choosing Wisely – from ABIM
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AMDA – The Society for Post-Acute and Long-Term Care Medicine
Released September 4, 2013
Don’t prescribe antipsychotic medications for behavioral and psychological
symptoms of dementia (BPSD) in individuals with dementia without an
assessment for an underlying cause of the behavior.
Careful differentiation of cause of the symptoms (physical or neurological versus
psychiatric, psychological) may help better define appropriate treatment options.
The therapeutic goal of the use of antipsychotic medications is to treat patients
who present an imminent threat of harm to self or others, or are in extreme
distress–not to treat nonspecific agitation or other forms of lesser distress.
Treatment of BPSD in association with the likelihood of imminent harm to self or
others includes assessing for and identifying and treating underlying causes
(including pain; constipation; and environmental factors such as noise, being too
cold or warm, etc.), ensuring safety, reducing distress and supporting the patient’s
functioning. If treatment of other potential causes of the BPSD is unsuccessful,
antipsychotic medications can be considered, taking into account their significant
risks compared to potential benefits. When an antipsychotic is used for BPSD, it is
advisable to obtain informed consent.
From ConsumerReports Health
• People with Alzheimer’s disease and other forms of
dementia can become restless, aggressive, or
disruptive. They may believe things that are not true.
They may see or hear things that are not there. These
symptoms can cause even more distress than the loss
of memory.
• Doctors often prescribe powerful antipsychotic drugs
to treat these behaviors:
• Aripiprazole (Abilify)
• Olanzapine (Zyprexa and generic)
• Quetiapine (Seroquel)
• Risperidone (Risperdal and generic).
From ConsumerReports Health
• In most cases, antipsychotics should not be
the first choice for treatment, according to the
American Geriatrics Society. Here’s why:
• Antipsychotic drugs don’t help much.
Studies have compared these drugs to sugar
pills or placebos. These studies showed that
anti-psychotics usually don’t reduce disruptive
behavior in older dementia patients.
From ConsumerReports Health
• Antipsychotic drugs can cause serious side effects.
• Doctors can prescribe these drugs for dementia. However, the Food
and Drug Administration (FDA) has not approved this use. The side
effects can be serious. Therefore, the FDA now requires the
strongest warning labels on the drugs.
• Side effects include:
• Drowsiness and confusion—which can reduce social contact and
mental skills, and increase falls
• Weight gain
• Diabetes
• Shaking or tremors (which can be permanent)
• Pneumonia
• Stroke
• Sudden death
From ConsumerReports Health
• Other approaches often work better.
• It is almost always best to try other
approaches first, such as the suggestions listed
below.
From ConsumerReports Health
• Make sure the patient has a thorough exam
and medicine review.
• The cause of the behavior may be a common
condition, such as constipation, infection,
vision or hearing problems, sleep problems, or
pain.
• Many drugs and drug combinations can cause
confusion and agitation in older people.
From ConsumerReports Health
• Talk to a behavior specialist.
• This person can help you find nondrug ways to
deal with the problem. For example, when
someone is startled, they may become
agitated. It may help to warn the person
before you touch them.
From ConsumerReports Health
• Consider other drugs first.
Talk to your healthcare provider about the
following drugs that have been approved for
treatment of disruptive behaviors:
• Drugs that slow mental decline in dementia.
• Antidepressants for people who have a history
of depression or who are depressed as well as
anxious.
From ConsumerReports Health
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Consider antipsychotic drugs if:
Other steps have failed.
Patients are severely distressed.
Patients could hurt themselves or others.
Start the drug at the lowest possible dose.
Caregivers and healthcare providers should watch
the patient carefully to make sure that symptoms
improve and that there are no serious side
effects. The drugs should be stopped if they are
not helping or are no longer needed.
Now what?
• If avoiding them is ‘Best Practice’, what do we
do if all else fails?
From CMS State Operations Manual:
guidance for surveyors
MEDICATION MANAGEMENT Medication management is based in the care process and
includes recognition or identification of the problem/need, assessment, diagnosis/cause
identification, management/treatment, monitoring, and revising interventions, as
warranted. The attending physician plays a key leadership role in medication management
by developing, monitoring, and modifying the medication regimen in conjunction with
residents and/or representative(s) and other professionals and direct care staff (the
interdisciplinary team).
From CMS State Operations Manual:
guidance for surveyors
• This guidance is intended to help the surveyor determine whether
the facility’s medication management supports and promotes:
• Selection of medications(s) based on assessing relative benefits
and risks to the individual resident;
• Evaluation of a resident’s signs and symptoms, in order to identify
the underlying cause(s), including adverse consequences of
medications;
• Selection and use of medications in doses and for the duration
appropriate to each resident’s clinical conditions, age, and
underlying causes of symptoms;
• The use of non-pharmacological interventions, when applicable, to
minimize the need for medications, permit use of the lowest
possible dose, or allow medications to be discontinued; and
• The monitoring of medications for efficacy and clinically significant
adverse consequences.
From CMS State Operations Manual:
guidance for surveyors
• V. Tapering of a Medication Dose/Gradual Dose Reduction
(GDR) The requirements underlying this guidance
emphasize the importance of seeking an appropriate dose
and duration for each medication and minimizing the risk of
adverse consequences. The purpose of tapering a
medication is to find an optimal dose or to determine
whether continued use of the medication is benefiting the
resident. Tapering may be indicated when the resident’s
clinical condition has improved or stabilized, the underlying
causes of the original target symptoms have resolved,
and/or non-pharmacological interventions, including
behavioral interventions, have been effective in reducing
the symptoms.
From CMS State Operations Manual:
guidance for surveyors
• Sometimes, the decision about whether to
continue a medication is clear; for example,
someone with a history of multiple episodes of
depression or recurrent seizures may need an
antidepressant or anticonvulsant medication
indefinitely. Often, however, the only way to
know whether a medication is needed
indefinitely and whether the dose remains
appropriate is to try reducing the dose and to
monitor the resident closely for improvement,
stabilization, or decline
From CMS State Operations Manual:
guidance for surveyors
• The time frames and duration of attempts to taper any
medication depend on factors including the coexisting
medication regimen, the underlying causes of symptoms,
individual risk factors, and pharmacologic characteristics of
the medications. Some medications (e.g., antidepressants,
sedative/hypnotics, opioids) require more gradual tapering
so as to minimize or prevent withdrawal symptoms or other
adverse consequences.
• NOTE: If the resident’s condition has not responded to
treatment or has declined despite treatment, it is
important to evaluate both the medication and the dose to
determine whether the medication should be discontinued
or the dosing should be altered, whether or not the facility
has implemented GDR as required, or tapering.
From CMS State Operations Manual:
guidance for surveyors
• Considerations Specific to Antipsychotics. The
regulation addressing the use of antipsychotic
medications identifies the process of tapering as a
“gradual dose reduction (GDR)” and requires a GDR,
unless clinically contraindicated. Within the first year in
which a resident is admitted on an antipsychotic
medication or after the facility has initiated an
antipsychotic medication, the facility must attempt a
GDR in two separate quarters (with at least one month
between the attempts), unless clinically
contraindicated. After the first year, a GDR must be
attempted annually, unless clinically contraindicated.
From CMS State Operations Manual:
guidance for surveyors
• For any individual who is receiving an
antipsychotic medication to treat behavioral
symptoms related to dementia, the GDR may be
considered clinically contraindicated if:
– • The resident’s target symptoms returned or
worsened after the most recent attempt at a GDR
within the facility; and
– • The physician has documented the clinical rationale
for why any additional attempted dose reduction at
that time would be likely to impair the resident’s
function or increase distressed behavior.
• For any individual who is receiving an antipsychotic
medication to treat a psychiatric disorder other than
behavioral symptoms related to dementia (for example,
schizophrenia, bipolar mania, or depression with psychotic
features), the GDR may be considered contraindicated, if:
The continued use is in accordance with relevant
current standards of practice and the physician has
documented the clinical rationale for why any attempted dose
reduction would be likely to impair the resident’s function or
cause psychiatric instability by exacerbating an underlying
psychiatric disorder; or
The resident’s target symptoms returned or worsened
after the most recent attempt at a GDR within the facility and
the physician has documented the clinical rationale for why
any additional attempted dose reduction at that time would
be likely to impair the resident’s function or cause psychiatric
instability by exacerbating an underlying medical or
psychiatric disorder.
CMS SOM
• Tapering Considerations Specific to Sedatives/Hypnotics.
• For as long as a resident remains on a sedative/hypnotic that is
used routinely and beyond the manufacturer’s recommendations
for duration of use, the facility should attempt to taper the
medication quarterly unless clinically contraindicated. Clinically
contraindicated means:
• • The continued use is in accordance with relevant current
standards of practice and the physician has documented the clinical
rationale for why any attempted dose reduction would be likely to
impair the resident’s function or cause psychiatric instability by
exacerbating an underlying medical or psychiatric disorder; or
• • The resident’s target symptoms returned or worsened after the
most recent attempt at tapering the dose within the facility and the
physician has documented the clinical rationale for why any
additional attempted dose reduction at that time would be likely to
impair the resident’s function or cause psychiatric instability by
exacerbating an underlying medical or psychiatric disorder.
• CMS SOM
• Considerations Specific to Psychopharmacological Medications (Other
Than Antipsychotics and Sedatives/Hypnotics).
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During the first year in which a resident is admitted on a
psychopharmacological medication (other than an antipsychotic or a
sedative/hypnotic), or after the facility has initiated such medication, the
facility should attempt to taper the medication during at least two
separate quarters (with at least one month between the attempts), unless
clinically contraindicated. After the first year, a tapering should be
attempted annually, unless clinically contraindicated. The tapering may be
considered clinically contraindicated, if:
• • The continued use is in accordance with relevant current standards of
practice and the physician has documented the clinical rationale for why
any attempted dose reduction would be likely to impair the resident’s
function or cause psychiatric instability by exacerbating an underlying
medical or psychiatric disorder; or
• • The resident’s target symptoms returned or worsened after the most
recent attempt at tapering the dose within the facility and the physician
has documented the clinical rationale for why any additional attempted
dose reduction at that time would be likely to impair the resident’s
function or cause psychiatric instability by exacerbating an underlying
medical or psychiatric disorder.
CMS SOM
Additional Resource
• When and How to Taper Antipsychotics for
Nursing Home Residents: Lessons from
Wisconsin
• Musicandmemory.org/2015/07/06 blog